In this chapter, the 1969 Peter Mazursky movie Bob & Carole & Ted & Alice is vivid in my mind. As Dr. Bob tries to develop a "professional" relationship with patient Alice, Carrier nurse Carole and lawyer Ted are running all sorts of interference to prevent that to happen. If Sigmund Freud was still around he will probably tell you that Dr Bob's mother and patient Alice's father maybe joining them too in that bed.
The straight-forward time-honored patient-doctor relationship has been long replaced by some Mazurskian or Freudian scheme that curtails and dilutes any possible interaction between the doctor and his patient. Often the quartet described above is replaced by a quintet or a sextet, including adjusters, nurse case managers, independent medical examiners, and so on and so forth. A number of characters have wedged themselves between Dr Bob and his patient Alice over the years and that number is growing.
First to suffer when that happens is the respect of the medical profession. The more Dr Bob's medical authority and proposed treatment are undermined and second-guessed by a variety of middlemen/ women, the less compelled patient Alice is to trust him, follow his advice and direction, appreciate his care and be loyal to him. Dr Bob has to deal with this frustrating fact as he also has to deal with nurse Carole, lawyer Ted and all the others. The result is less time to devote to patient Alice, less drive to heal, thus even less respect and more disengagement of patient Alice.
The underpinning of this Ménage à Quatre, à Cinq ou à Six is money: who is footing the bill for this physician encounter? This reminds me of a wall sign I saw in Piccadilly Circus during my first trip to London in 1973: "HE WHO HAS THE GOLD MAKES THE RULES" and boy he lets you know it and feel it. As long as patients expect some third party to pay the doctor for their visit, thus dictating all the terms of this visit, the time-honored patient-doctor relationship will soon be a thing of the past if it is not already. Patient Alice went to Dr Bob only because she was told to by her lawyer Ted or because she saw his name in nurse Carole's carrier's directory. Hence her loyalty will tend to reside with Carole and/or Ted and not Bob. Furthermore they are paying the bill!
To give you an idea of how intrusive these "middlemen" can be, two examples come to mind: One day, about a year ago, I received a phone call from a physician (he said he was) from another state asking me why I put one of my patients on Naprelan (extended release Naprosyn, a common NSAID) and not on the generic Naprosyn. It took about 15 minutes of my precious time to explain to him why, in this particular patient, one was better than the other even though a bit more expensive. Two doctors had to joust about some basic drug and waste their time so that the carrier saves some money. One day soon I may receive a call questioning my use of St Joseph Aspirin instead of Bayer and the list can go on and on. Of course lawyers (and insurance docs) get reimbursed for phone calls per six-minute units but treating physicians never do.
Another time, my staff had requested an authorization from a carrier to perform a minimally invasive spinal procedure. A few days later a neurosurgeon (he said he was) called on behalf of the carrier asking me to describe step-by-step the procedure I was going to perform prior to approving it, especially whether I was going to visualize the nerve root or not! Needless to say that I usually try to stay clear from the nerve root. Next they will have spy cameras in the OR capturing the entire procedure then deciding what frame they may pay for and how much. Here goes Clinton's Patient Privacy Act.
It is my contention that unless the patient is paying for his/her doctor visit, s/he will not be able to select the doctor s/he wants and trust and respect this doctor, thus minimizing second-guessing, treatment delays and frivolous law suits. Doctors visits need not be expensive (sliding scales are common) and patients can receive receipts to submit to their carriers and battle for reimbursement. Health insurance coverage should be focused primarily on catastrophic occurrences and not on run-of-the-mill doctors visits.
Eliminating the middlemen is maybe utopic because of all the different interests involved, but it is the only way to restore the patient's sense of responsibility for his/her health under the direct guidance of his physician. Pay a flat fee for the visit and instead of wasting time and energy trying to figure out deductibles, copays, donut holes or out-of-pocket, focus that energy on getting better under your trusted doctor's guidance. This is exactly what happens in a lot of less advanced countries in the world, where the medical profession is still highly respected, and their healthcare is not all the worse.